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A meta-synthesis of fathers׳ experiences of their partner׳s labour and the birth of their baby
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A meta-synthesis of fathers' experiences of their partner's labour and the birth of their baby M. Johansson RN RM PhD, J. Fenwick RM PhD, Å. Premberg RN RM PhD
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S0266-6138(14)00127-2 http://dx.doi.org/10.1016/j.midw.2014.05.005 YMIDW1541
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Received date: 19 February 2014 Revised date: 29 April 2014 Accepted date: 4 May 2014 Cite this article as: M. Johansson RN RM PhD, J. Fenwick RM PhD, Å. Premberg RN RM PhD, A meta-synthesis of fathers' experiences of their partner's labour and the birth of their baby, Midwifery, http://dx.doi.org/10.1016/j.midw.2014.05.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
A META-SYNTHESIS OF FATHERS’ EXPERIENCES OF THEIR PARTNER’S LABOUR AND THE BIRTH OF THEIR BABY
Authors: Johansson M RN RM PhD Senior lecturer₁, Fenwick J RM PhD Professor₂, Premberg Å RN RM PhD Research Leader₃
₁ Corresponding Author: Karolinska Institutet Södersjukhuset, Department of Clinical Science and Education, Sjukhusbacken 10, SE-118 83 Stockholm, Stockholm, Sweden. Fax number: +46 8 616 20 89; Telephone number: +46 70 241 52 75; E-mail: [email protected]
₂ School of Nursing and Midwifery, Centre for Health Practice Innovation (HPI), Griffith Health Institute, Griffith University, University Drive, Meadowbrook , Queensland 4131. Clinical Chair Gold Coast University Hospital, Parklands Queensland, Australia. Telephone number: +61410479985; E-mail: [email protected]
₃ Primary Health Care, Research and Development Unit, Närhälsan, Kungsgatan 12, Gothenburg, Sweden. Telephone number: +46706653157; E-mail: [email protected]
ABSTRACT Objective: To develop greater understanding of how expectant fathers experience their partner’s labour and the subsequent birth of their baby. Design: A qualitative meta-synthesis. Data were search for in CINAHL, PubMed, Psych Info and SCOPUS. Setting: Eight studies conducted in England, Malawi, Nepal and Sweden were included. Participants: One hundred and twenty fathers with experiences of their partner having a spontaneous vaginal, assisted or surgical birth. Measurements and Findings: 1st order themes were identified and subsequently grouped into seven 2nd order themes. Finally through a process of exploring patterns and connections seven 3rd order themes were developed which produced new insights into the men’s experiences of labour and birth. This meta-synthesis revealed that most men wanted to be actively involved in their partner’s labour, present at the birth and respected for what they could contribute. Men recognised that birth was a unique event that may be potentially challenging requiring a level of preparation. There were also men who felt pressured to attend. During the actual experience of labour men commonly expressed overwhelming feelings and inadequacy in their ability to support their partner. They particularly struggled with the ‘pain’ of labour. Midwives were subsequently identified as best placed to make a significant difference to how men perceived their experiences of labour and what they described as the life changing event of birth. Key conclusions: The expectant fathers’ birth experiences were multidimensional. Many were committed to being involved during labour and birth but often felt vulnerable. Being prepared and receiving support were essential elements of positive experience as well as contributing to their ability to adequately support the labouring woman. Implications for practice: Men’s ability to actively prepare for, and be supported through, the labour and birth process influences their perceptions of the childbirth event as well as their sense of connection to their partner. Couples should be given opportunities to explore expectations and how these may influence their own construction of their role during the birth process. While the role of expectant fathers in labour and birth should be facilitated and supported arguably their wish not to participate should be afforded the same respect. Keywords: childbirth; experience; fathers; meta-synthesis
INTRODUCTION In most western nations expectant fathers are encouraged to be involved and actively participate in their partner’s labour and the subsequent birth of their infant. Men, however, often report the experience of labour and birth as demanding and one that evokes a range of contradictory emotions (Johansson et al., 2012). For example some time ago Hallgren et al. (1999) described how men could go from feeling overwhelmed and helpless to expressing the experience of witnessing the birth as “the best in life” (p.12). Anxiety in pregnancy is a common emotion (Capogna et al., 2007; Rosich-Medina and Shetty, 2007) as is vulnerability both of which are linked to men’s feelings of uncertainty surrounding the labour and birth process and the role they are expected to play (Sengane, 2009; Draper, 2003). Negative emotions are also commonly fuelled by expectant fathers’ fears for the safety of their partner and the unborn baby (Vehviläinen-Julkunen and Liukkonen, 1998; Eriksson et al., 2007). Despite this there is evidence that men can regard the experience as positive (Johansson et al., 2012) especially when they perceived they are well supported by the midwives providing care to their female partner (Johansson et al., 2012; Lindberg and Engström, 2013).
The growing body of qualitative work and the development of methodological techniques to synthesis the findings of individual qualitative studies has facilitated the research communities ability to create new and integrative interpretations that are greater than the sum of each included study (Flemming, 2007). As a result qualitative meta-synthesis has become increasingly popular. For example in a recent meta-synthesis of 23 qualitative studies by Steen et al. (2012) explored the experiences of men in relation to pregnancy, birth and the first six months of fatherhood. A number of major themes were identified that produced insights into issues such as risk, uncertainty, exclusion, support and the reality of fatherhood. Similarly Chin et al. (2011) explored fathers' experiences of their transition to fatherhood. Eight articles were examined and three themes extracted that described men’s emotional reactions to their role as a new father, how they redefined their sense of self as well as their relationship with partner. These findings add to the earlier work of Goodman (2005) who used the same approach to synthesis the findings from ten articles with the intention of describing men’s experiences of fatherhood from birth to 20 months. In this work new insights were gained into men’s expectations and intentions, how they learned to confront the reality of their role as an involved father and how it could be an emotional rewarding experience. More recently Dheensa et al. (2013) published a meta-synthesis that examined men's experiences of
antenatal screening. From the 18 qualitative studies men’s emotional conflict early in pregnancy, their focus on gaining information and how they subsequently influenced decision-making on screening were explored.
Conducting a qualitative meta-synthesis is one way to make sense of the available literature and is becoming increasingly popular. Although used somewhat extensively in the area of men’s childbirth experience the majority of work has focused on the entire childbirth episode including transition to fatherhood. There has been limited work on using the technique of meta-synthesis to examine only one aspect of men’s experiences such as the labour and birth process. Using a more targeted approach is likely to assist in establishing a greater understanding of how men integrate this unique experience and thus provide maternity health care professionals with additional strategies to ensure women and their partners have a positive experience of childbirth. The aim of this study was therefore to develop greater understanding of how expectant fathers experience their partner’s labour and the subsequent birth of their baby.
METHODS Study design The techniques described by Major and Savin-Baden (2010) guided the process of our quality research synthesis which included four distinct levels: (i) systematic approach to the identification of articles, (ii) analysis of the themes common to all selected studies resulting in the identification of what are commonly referred to as 1st order themes, (iii) synthesis of data across studies producing 2nd order themes and finally (iv) interpretation which generated the 3rd order themes or findings of the meta-synthesis. During this process concepts, metaphors and quotes were used to form patterns in the synthesized interpretation.
Identification of articles With the intension to get a wide sample of articles covering the subject of interest we chose databases from different disciplines; CINAHL, PubMed, Psych Info and SCOPUS. The keywords used were “father “OR “dad “OR “male” OR “man” AND “childbirth” OR “parturition” AND “experience” AND “qualitative”. The terms were varied according to the
index system of each database. Other parameters included were articles written in English and published in 2000 or later in peer-reviewed journals. The database searches were repeated with the last occasion being June the 19th 2013. A template for inclusion and exclusion criteria was created in order to guide our review. An article was included if it described a qualitative study that aimed to explore fathers’ experience of their partner’s labour and birth (including spontaneous vaginal birth, assisted delivery and caesarean section). Studies with disparate geography or cultural backgrounds were included if they met the inclusion criteria. The rationale for this decision was to ensure a global view of fathers’ birth experiences was represented. Articles were excluded when couples were the participants, pregnancy and fatherhood were the focus of the study and if a quantitative or mixed method design had been used. The judgment for inclusion was based on the title and subsequently the abstract. If it was unclear then the entire article was read and assessed against the inclusion and exclusion criteria. In the database CINAHL we received 22 hits and of these two articles were included in our qualitative meta-synthesis (Erlandsson and Lindgren, 2009; Johnson, 2002). In PubMed 33 hits were retrieved and three included (Johansson et al., 2013; Kululanga et al., 2012; Premberg et al., 2011). Eighteen articles were found in Psych Info but none fulfilled the inclusion criteria. Finally 129 hits were received in SCOPUS and of these six were included (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Kululanga et al., 2012; Longworth and Kingdon, 2011; Premberg et al., 2011; Sapkota et al. 2012). Two of the authors (MJ, ÅP) independently assessed the papers for inclusion, and the final number (n=8) was then agreed by consensus of all three authors. Table 1 presents the mapping of methods, concepts and findings of the included studies. The included articles were also assessed for quality using the criteria developed by Walsh and Downe (2006); see Table 2 for further details. Analysis In the next stage we scrutinized the included articles looking for common features. Firstly all the themes from each study were listed. In this way we commenced the process of identifying apparent relationships across the studies. Questions such as ‘Which findings were clear?’ and ‘Which themes were explored?’ guided the process. Subsequently concepts within themes were extracted and compared across studies. Seven themes were identified that were common
across all the studies. These were labeled as 1st order themes and described as ‘Wanted to be present’, ‘Being involved or not’, ‘The impact of being prepared’, ‘Relationship with partner’, ‘Feelings experienced’, ‘A life change that is unknown’, and finally, ‘The staff played an important role’ (Table 3). Synthesis data across studies In the next phase of the meta-synthesis process ‘data’ used to highlight the themes were extracted. Similarities and differences were identified through a process of constant comparison. In this way seven 2nd order themes emerged that created new perspectives of the fathers’ experiences of labour and birth (Major and Savin-Baden, 2010 p.63). These themes were labeled: ‘Being there’, ‘Issue of involvement’, ‘Being prepared’, ‘Being sensitive to my partner’, ‘Experiencing overwhelming feelings’, ‘A crucial change in my life’ and ‘Being influenced by staff’ (Table 4). Interpretation of data The final step in the process involved reviewing patterns and connections between the 1st and 2nd order themes. At this level, metaphors, concepts and contexts were also compared. This involved carefully re-reading the included studies and examining each one for relationships between the developed themes. Data was discussed between the authors, synthesized and eventually the authors agreed on the construction of five 3rd order themes (shown in Table 3 and described below). Ethics Seven studies included a statement about ethics approval. While the article by Johnson (2002) did not the research design was considered to be ethically sound. In all papers study participants were anonymous and direct quotes could not be attributed to an identified individual.
FINDINGS The eight qualitative studies included in the meta-synthesis involved 120 fathers from four countries (England, Malawi, Nepal and Sweden). While the majority of men’s experiences were those related to their partner having a spontaneous vaginal birth men experiences of the
labour process leading to other birth modes were also represented within the themes as there was little differentiation in the data set (Table 1). Five 3rd order themes were developed using the process outlined above. In a meta-synthesis these become the final findings of the study (Major and Savin-Baden, 2010). These 3rd order themes were labeled; ‘Desiring respectful participation’, ‘Preparing for the unique challenge of birth’, ‘Midwives make a difference’, ‘Being supportive was emotionally challenging’ and ‘The birth: agony to ecstasy’ (Table 3).
Desiring respectful participation The vast majority of expectant fathers described a strong desire to participate in their partner’s labour and be present at the birth of their child (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Kululanga et al., 2012; Premberg et al., 2011). Men were keen to provide physical and emotional support to their partner. For many the decision to ‘be there’ was not something they consciously thought about but was rather an expectation (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Johansson et al., 2013). Likewise others described the decision to attend their partners labour and birth as ‘natural’ (Premberg et al., 2011) and/or expressed the importance of being part of the team (Johnson, 2002; Longworth and Kingdon, 2011). Men articulated how important it was that their status as the father of the baby be acknowledged and that their presence be ‘valued’ (Kululanga et al., 2012; Sapkota et al., 2012). Men wanted to be considered as a ‘part of the labouring couple’ (Backstrom and Hertfelt Wahn, 2011 p.70) and as integral to the process of birth (Premberg et al., 2011). In addition men believed that ‘being present’ was about being ‘a good father’ which reflected their commitment to their partner and family unit (Johnson, 2002 p.176). For these men feeling actively engaged, involved and providing support to their partner was important and an essential element of a positive experience (Johnson, 2002; Kululanga et al., 2012). Physical support regularly included holding their partners hand (Erlandsson and Lindgren, 2009; Premberg et al., 2011; Sapkota et al., 2012) , talking to her, and standing by her side (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Johansson et al., 2013; Johnson, 2002; Kululanga et al., 2012; Longworth and Kingdon, 2011; Premberg et al., 2011; Sapkota et al., 2012). If and when their female partner was distressed men talked about trying to calm them through body contact and by talking (Erlandsson and Lindgren, 2009). Providing comfort (Johnson, 2002), being their partner’s advocate and ‘spokesman’ and interpreting her needs (Kululanga et al., 2012; Premberg et al.,
2011) were common emotional support activities. Supporting the woman also meant ‘protecting’ her. This involved ‘filtering’ information and ‘pleading’ for her wishes to prevent and/or reduce the risk of her getting upset (Premberg et al., 2011). Providing support created a feeling of involvement and security in the men (Backstrom and Hertfelt Wahn, 2011). In addition participating and being present at the birth was viewed as a unique and exclusive opportunity to ‘bond’ with their new-born (Johnson, 2002; Kululanga et al., 2012).
Not surprisingly some men described feeling hesitant whilst also curious about being present and involved (Kululanga et al., 2012; Sapkota et al., 2012). Others articulated, however, that the decision to participate in their partners labour and birth was based on the expectation of others such as partners (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Johnson, 2002; Kululanga et al., 2012; Sapkota et al., 2012), peers (Kululanga et al., 2012) and health care professionals (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Johnson, 2002). Still other men in this meta-synthesis had not expected to be present at all (Longworth and Kingdon, 2011) while the work of Sapkota et al. (2012) highlighted men’s experiences in a cultural context where it was not common for men to be ‘birth companions’ to their partners. What was evident during the synthesis process was that when men had been hesitant but encouraged to be present at the birth they more commonly reported feelings of helplessness and frustration (Kululanga et al., 2012; Sapkota et al., 2012) while others talked about being “in the way” (Johnson, 2002 p.174).
Preparation for the unique challenge of birth Childbirth was considered ‘unknown territory’ for most first-time fathers (Johansson et al., 2013; Premberg et al., 2011; Sapkota et al., 2012) ‘To tell you the truth, I didn’t know about childbirth’ (Sapkota et al., 2012 p.47). As such men’s mental and physical preparation was seen as not only vital but crucial to their ability to be actively involved in the labour and birth process (Backstrom and Hertfelt Wahn, 2011; Johansson et al., 2013; Longworth and Kingdon, 2011; Premberg et al., 2011; Sapkota et al., 2012). As one first-time father said: ‘Husbands should be mentally prepared … the birthing process could be discussed… we could be informed about how to help our wives’ (Sapkota et al., 2012 p.48). Preparation consisted of reading (Backstrom and Hertfelt Wahn, 2011), talking to friends (Backstrom and Hertfelt Wahn, 2011; Johnson, 2002), and attending antenatal classes (Backstrom and Hertfelt Wahn, 2011; Johnson, 2002; Longworth and Kingdon, 2011). For some preparing with the woman was especially important (Backstrom and Hertfelt Wahn, 2011; Johansson et al.,
2013; Premberg et al., 2011; Sapkota et al., 2012). Fathers, who attended antenatal classes, were deemed to be better positioned to be actively involved during birth (Longworth and Kingdon, 2011). Likewise those men attending classes were better prepared to support the woman and to cope with labour and any critical events during the process (Johnson, 2002). Men with previous birth experiences usually drew on these which ultimately enhanced feeling of preparedness generating feeling of positivity and a sense of control. ‘We knew what to expect, and we had a good experience from the first surgery, we could relay pretty much on our previous experience’ (Johansson et al., 2013 p.6).
A lack of preparation for the labour and birth process was more likely to create feeling akin to being ‘out of control’ (Johnson, 2002; Longworth and Kingdon, 2011) which subsequently hampered men’s ability to undertake a ‘supportive’ role (Johnson, 2002). In this state unfamiliar birth environments were experienced as ‘scary’; ‘if I was better prepared for what was going to happen, I would have been more use to her (partner)…’ (Johnson, 2002 p.177). Furthermore, when lacking confidence fathers experienced an inability to support the woman physically (Sapkota et al., 2012). In the case of a caesarean section, the fathers were not always prepared for being present in the theatre which was a challenging experience. In these circumstances receiving continuous information from the health care professionals involved was crucial; ‘They talked the whole time and explained and said what they were doing ... that was very good’ (Johansson et al., 2013 p.5).
Midwives make a difference The level of engagement and active involvement that men experienced during the labour and birth process depended greatly on the quality of communication and interactions they shared with health care professionals. Positive respectful behaviour and language by professionals impacted greatly on men’s sense involvement (Johansson et al., 2013; Premberg et al., 2011). Being continually kept informed generated feelings of safety and inclusion (Backstrom and Hertfelt Wahn, 2011; Johansson et al., 2013) and consequently made a significant difference to the men’s sense of control (Johansson et al., 2013; Longworth and Kingdon, 2011).
When men perceived they were working in partnership with the midwife they felt more able to support their partners which subsequently enhanced their feelings of being ‘useful’ (Premberg et al., 2011). As one first-time father said: ‘The support I got was that they answered my questions ... and when they gave good answers it calmed me, and when I was
calm my girlfriend was too…’ (Backstrom and Hertfelt Wahn, 2011 p.69). The men appreciated midwives providing instructions on how to provide additional physical support (Backstrom and Hertfelt Wahn, 2011; Premberg et al., 2011) such as massage (Backstrom and Hertfelt Wahn, 2011; Premberg et al., 2011; Sapkota et al., 2012) and breathing techniques (Backstrom and Hertfelt Wahn, 2011; Johnson, 2002; Sapkota et al., 2012), how to assist their partner effectively use the nitrous oxide (Backstrom and Hertfelt Wahn, 2011) and how to ensure their partners stayed well hydrated and energised (Sapkota et al., 2012). Another firsttime father said: ‘I felt good when the midwife showed me, because then I was able to be involved’ (Backstrom and Hertfelt Wahn, 2011 p.70). Likewise health care professional needed to demonstrate through their actions that men had ‘permission’ to not only be present in the birth space but to ‘own’ it (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Premberg et al., 2011). An important consequence of positive interactions was that when men felt ‘safe’ they could relax and were more able to accept and trust the process of birth (Backstrom and Hertfelt Wahn, 2011).
However there was evidence that health care professionals were not always attentive to men’s needs or provided them with a high level of support. If men were unable to receive the information they needed they became less involved and felt insecure. In situations like these men often tried to find out what was going on by reading the faces and gesture of the professionals (Johansson et al., 2013; Premberg et al., 2011). A father, who experienced his partner’s emergency caesarean section, said: ‘They didn’t tell me what happened… It would have been better had they done this… That would have made me feel more secure’ (Johansson et al., 2013 p.5). While positive interactions were applauded negative ones could be incredibly detrimental. In one study an expectant father recounted how a midwife had told him the reason men were present at birth was to ‘teach them a lesson’ (Johnson, 2002 p.174). Premberg et al. (2011) demonstrated how men could be forced to undertake an activity they didn’t want or had not agreed to when a new father being passed the scissors to cut his newborn’s umbilical cord even though he had previously stated this is something he did not want to do. Hospital routines and feeling unwelcome in the space also acted as obstacles to men being able to engage in a positive way. When men were left out or ignored their sense of disconnection lead not only to frustration and distress (Johnson, 2002) but often forced men to take a passive role in terms of supporting their partner (Johnson, 2002; Longworth and Kingdon, 2011).
Being supportive was emotionally challenging Regardless of the preparation undertaken, their level of involvement and the support of staff, being a strong calm companion in the process of childbirth could be challenging and emotionally overwhelming experience for men (Erlandsson and Lindgren, 2009; Sapkota et al., 2012). A woman’s ability to manage her labour and work with her contractions commonly influenced her male partner’s experience; if she could cope with labour pain he remained ‘calm’ (Premberg et al., 2011). Alternatively as the pain of labour increased, men reported becoming less able to deal with the situation (Johansson et al., 2013; Johnson, 2002; Kululanga et al., 2012; Premberg et al., 2011). In addition, any perceived ‘conflict’ around pain relief caused men stress (Johnson, 2002). Watching their partner was described as ‘hard’ and often gave rise to overwhelming feelings of despair (Erlandsson and Lindgren, 2009; Premberg et al., 2011), frustration (Erlandsson and Lindgren, 2009; Kululanga et al., 2012; Premberg et al., 2011; Sapkota et al., 2012), helplessness (Erlandsson and Lindgren, 2009; Johansson et al., 2013; Johnson, 2002; Premberg et al., 2011) and powerlessness (Johnson, 2002). Men really struggled with knowing what to do (Johnson, 2002; Kululanga et al., 2012; Sapkota et al., 2012) or how to help ease their partner’s pain. Commonly these feelings lead men to feel like they had failed their partner in some way (Kululanga et al., 2012). Likewise men often struggled to support their partners (Backstrom and Hertfelt Wahn, 2011; Johnson, 2002) in adverse circumstances such as bleeding or when an assisted birth was required (Johansson et al., 2013; Sapkota et al., 2012). In these situations men described ‘fighting’ to remain calm, ‘hiding’ their emotions and ‘chocking back tears’ in order to sustain and support their partner (Erlandsson and Lindgren, 2009; Premberg et al., 2011; Sapkota et al., 2012); ‘I was telling her not to worry, but I myself was worried deep inside’ (Sapkota et al., 2012 p. 48). Being physically present, whilst at the same time feeling somewhat ‘sidelined’ or a ‘by-stander’ in the events going on around them, was a difficult position for the men to assume (Johansson et al., 2013; Longworth and Kingdon, 2011). Again the dominant emotions elicited were stress, panic, fear and helplessness. ‘I wanted to help, but I felt left out, I could not do anything ... I wanted to help somehow, but could not‘ (Backstrom and Hertfelt Wahn, 2011 p.71). Although having another female relative or support person present often reduced men’s anxiety but this was not always the case.
The birth: agony to ecstasy During the labour process men’s emotions fluctuated. To some extent regardless of how well labour was progressing most men worried that something might go ‘wrong’. For some these fears resulted in men constructing childbirth as ‘life-threatening’ (Erlandsson and Lindgren, 2009; Johnson, 2002; Premberg et al., 2011) where they envisaged either the woman, her baby or both could die (Erlandsson and Lindgren, 2009; Johansson et al., 2013; Kululanga et al., 2012; Premberg et al., 2011). Men found it hard to compare the moment of their child’s birth with any other experience; words such as ‘happiness’ (Erlandsson and Lindgren, 2009; Johansson et al., 2013; Premberg et al., 2011) and ‘proud’ (Erlandsson and Lindgren, 2009) were common as was ‘relief’ (Erlandsson and Lindgren, 2009; Johansson et al., 2013; Premberg et al., 2011). ’I was overwhelmed with joy to see our new baby. It was amazing that at the same time all the pain my partner was experiencing ceased’ (Kululanga et al., 2012 p.5). The strength and overwhelming nature of the emotions fathers ‘felt’ at ‘seeing’ their baby born were somewhat unexpected and commonly described as taking them by ‘surprise’ (Erlandsson and Lindgren, 2009; Johnson, 2002; Kululanga et al., 2012). In Johnson’s (Johnson, 2002) work the act of cutting the umbilical cord was steeped in emotion as it symbolised men’s ‘rite of passage’ to separate one into two (Johnson, 2002). For men the moment of birth represented the time that they actually became a father which they ultimately considered to be life changing event (Erlandsson and Lindgren, 2009; Johansson et al., 2013; Johnson, 2002; Kululanga et al., 2012; Longworth and Kingdon, 2011; Premberg et al., 2011); ‘It was pure joy, I didn’t know whether to laugh or to cry (Longworth and Kingdon, 2011 p.591).
DISCUSSION As previous research has highlighted, the majority of men included in this meta-synthesis expressed a desire to participate in and support their female partner during the labour and birth process (Abushaikha and Massah, 2012; Dellman, 2004; Eriksson et al., 2007; Gungor, 2007; Simbar et al., 2010). Men wanted to be actively involved and of some practical help to their partner. This may be a reflection of the reality that half of the studies included in the analysis were of Swedish origin where fathers’ involvement is commonly constructed as a social ‘norm’. Asserting the right to participate also appeared to be a reflection of men’s need to be acknowledged as an important partner in the childbirth process and an avenue through
which they could establish a ‘connection’ with their new-born infant (Eriksson et al., 2007; Simbar et al., 2010; Vehvilainen-Julkunen and Liukkonen, 1998). Arguably this could be the result of work that has consistently demonstrated men feel left out or side-lined during a woman’s pregnancy (Fenwick et al., 2012). Not with-standing there were men who felt participation was an expectation of their partner and/or midwife rather than a free choice (Bartlett, 2004; Dellman, 2004; Eriksson et al., 2007).
Regardless of expectations around participation our analysis revealed that for male partners labour and birth was a unique life event which held a number of potential challenges. Preparing, not only for the event itself, but to actively support their female partner was considered important by most. Indeed the work of Kainz et al., (2010) argues that men’s ability to communicate the woman’s wishes and engender feeling of security plays a significant role in the facilitating a positive experience for them both. However, in line with the findings of others (Bartlett, 2004; Genesoni and Tallandini, 2009; Hallgren et al., 1999) many men described feeling mentally ill prepared for such an emotionally charged event. The unpredictable nature of labour and birth, and their partner’s reaction to the pain of labour were particularly influential. As a result, and similar to the previous findings of a literature review undertaken by Genesoni and Tallandini (2009), men often struggled to support their partners, felt uncomfortable, distressed and vulnerable in the birth space, and expressed the need for additional support for themselves. Certainly positive support from midwives and/or other maternity health care professionals made a significant difference to the men’s experiences. As others have found (Danerek and Dykes, 2008; Grobman et al., 2010; Hildingsson et al., 2011; Johansson et al., 2012) the level of involvement that men experienced during the labour and birth process depended greatly on the quality of communication and interactions they shared with health care professionals. Expectant fathers appreciated receiving information in an honest manner (Danerek and Dykes, 2008), and being provided with clear information so they could more fully understand the situation and be better able to participate in decision making (Grobman et al., 2010). When men perceived they were working in partnership with the midwife they felt more able to support their partners which subsequently enhanced their feelings of being ‘useful’. In a meta-synthesis of fathers’ experiences of pregnancy, birth and maternity care Steen et al. (2012) identified that good support from clinicians helped men to manage and balance the emotional work associate with their partners labour and birth.
On the contrary a lack of support left men feeling worried, helpless and unsafe irrespective of cultural background. Being given little or no information or inconsistent advice has been described as distressing by expectant fathers (Johansson et al., 2012). In other work where expectant fathers perceived their partners received poor care and midwives were considered obstructive men expressed high levels of dissatisfaction (Johansson and Hildingsson, 2013).
Men’s own gendered preconceptions might also impact on their ability to positively participate during childbirth. Anthropologists Angelova and Temkina (2010) have described two models of role participation for fathers in childbirth. The first, labelled the family orientated role, talks about full participation, partnership and appropriate training, which has many similarities with the descriptions of some of the men in our analysis. The second model, described as situational and formal, is a reflection of the more masculine hegemony role of men which includes the tasks of observing and controlling. It may be that when men become distressed they are more likely to relapse into a masculine hegemonic way of behaving which automatically places them in a ‘spectator’ role (for example watching a piece of machinery as opposed to lending psychical support to partner during contractions). Taking a ‘distant’ or disengaged position (Johnson, 2002; Longworth and Kingdon, 2011) may enhance feelings of distress and an inability to manage or cope with the situation at hand. Dolan and Coe (2011) interpretations are useful here as they advocate that for men to be truly present during labour and birth they need to shed the traditional masculine values of power and control. Not surprisingly in cultures where participation in childbirth is a rather new occurrence men’s experience of feeling distant and distressed, as described in Kululanga (2012) and Sapkota et al. (2012), is likely to have its origins in the traditional construction of gender roles. In addition a lack of privacy in the labour room and unfriendly staff were other issues that made participation difficult for expectant fathers in developing countries.
Facilitating opportunities for new, as well as, fathers with previous birth experiences to engage with each other may be one strategy that would better help men gain more realistic expectations around the labour and birth process and feel better prepared (Premberg and Lundberg, 2006; Symon and Lee, 2003). Having said this there is evidence that some men do not seek out opportunities to prepare for birth. Certainly authors such as Case et al. (2005) and earlier Baker and Pettigrew (1999) have highlighted how, when faced with a perceived
stressful situation, avoiding information becomes a common coping strategy as ‘paying attention’ actually causes mental discomfort (Case et al., 2005). Behavior of this nature has been termed ‘blunting’ (Greenhalgh et al., 2000 p.179). Work by Greenhalg et al. (2000) showed that male ‘blunters’ attending antenatal classes were less likely to have a fulfilling childbirth experience compared to those with similar coping styles who did not attend classes. Arguably it may be that men engage in this type of avoidance behavior because they are fearful. For example Swedish researcher Eriksson et al. (2007), when exploring fathers’ experiences of childbirth fear, described how expectant fathers routinely kept themselves occupied with other activities and made excuses for not engaging in an effort to withdraw themselves from situations where the forthcoming childbirth might be discussed.
Methodological considerations Conducting a qualitative research synthesis is a way of making sense of the available literature and developing new understanding that can inform practice. An initial core issue in conducting a qualitative meta-synthesis is deciding which studies are about the same phenomenon (Sandelowski et al., 1997). In this study we focused therefore exclusively on fathers’ birth experiences of labour and birth as opposed to others who have included pregnancy and/or early fatherhood (Chin et al., 2011; Goodman, 2005; Steen et al., 2012). We found, however, that few of the qualitative studies had used similar methodological approaches. Arguably one could question whether it is appropriate and subsequently possible to synthesize such data given the different and sometimes contradicting ways that data sets are handled. Nevertheless, the qualitative paradigm considers truth as subjective and multiple, and knowledge as constructed. As such Walsh and Downe (2005) argue the legitimacy of including a variety of approaches in a meta-synthesis. In line with this argument we made the decision to include a range of study methodologies and to include not only the final description of the analysis but all the direct published quotes. Quotes from the primary sources were used to generate a ‘rich description’ and maintain sensitivity to the original language. In addition we included descriptive tables of the included studies as well as analysis tables describing how the themes were emerged (Walsh and Downe, 2005). Taking this approach we believed strengthened the trustworthiness and credibility of the study findings ensuring they were open and transparent (Major and Savin-Baden, 2010).
Notwithstanding the synthesis relied on published results and not original data. Furthermore, no unpublished i.e. ‘grey literature’ or studies not written in English were included. This may lead to publication bias. However large sample size may impede deep analysis. As Bondas and Hall (2007) recommend no more than ten articles should be included in a meta-synthesis.
Conclusion and clinical implications The fathers’ birth experiences were complex and multidimensional. While many men felt committed to the concept of being involved and supportive during their partners labour and birth they subsequently found themselves feeling vulnerable, confused and distressed. Being prepared and receiving sufficient information and situational support were key components of a positive birth experience. The actual moment of ‘birth’ was considered by most to be a life changing event. Positive respectful behaviour and language by professionals impacted greatly on men’s sense of involvement. Being continually kept informed generated feelings of safety and inclusion and consequently made a significant difference to the men’s sense of self. Couples should be given opportunities to explore expectations and how these may have influenced their own construction of their role. While men’s role to participate should be respected arguably their wish not to participate should be afforded the same respect.
REFERENCES Abushaikha, L., Massah, R., 2012. The roles of the father during childbirth: the lived experiences of Arab Syrian parents. Health Care for Women International 33, 168181. Angelova, E., Temkina, A., 2010. The Father Who Participates in Childbirth. Anthropology & Archeology of Eurasia 49, 9-43. Backstrom, C., Hertfelt Wahn, E., 2011. Support during labour: first-time fathers' descriptions of requested and received support during the birth of their child. Midwifery 27, 67-73. Baker, L. M., Pettigrew, K. E., 1999. Theories for practitioners: two frameworks for studying consumer health information-seeking behavior. Bulletin of the Medical Library Association 87, 444-450. Bartlett, E. E., 2004. The effects of fatherhood on the health of men: a review of the literature The Journal of Men's Health & Gender 1, 159-169. Bondas, T., Hall, E.O.C., 2007. A decade of metasynthesis research in health sciences: a meta-method study. International Journal of Quality Studies on Health and Well-being 2, 1748-2623. Capogna, G., Camorcia, M., Stirparo, S., 2007. Expectant fathers’ experience during labor with or without epidural analgesia. International Journal of Obstetric Anesthesia 16, 110-115.
Case, D. O., Andrews, J. E., Johnson, J. D., Allard, S. L., 2005. Avoiding versus seeking: the relationship of information seeking to avoidance, blunting, coping, dissonance, and related concepts. Journal of the Medical Library Association 93, 353-362. Chin, R., Hall, P., Daiches, A., 2011. Fathers' experiences of their transition to fatherhood: a metasynthesis. Journal of Reproductive and Infant Psychology 29, 4-18. Danerek, M., Dykes, A. K., 2008. A theoretical model of parents' experiences of threat of preterm birth in Sweden. Midwifery 24, 416-424. Dellman, T., 2004. "The best moment of my life": a literature review of Fathers' experience of childbirth. Australian Midwifery 17, 20-26. Dheensa, S., Metcalfe, A., Williams, R. A., 2013. Men's experiences of antenatal screening: a metasynthesis of the qualitative research. International Journal of Nursing Studies 50, 121-133. Dolan, A., Coe, C., 2011. Men, masculine identities and childbirth. Sociology of Health & Illness 33, 1019-1034. Draper, J., 2003. Men’s passage to fatherhood: an analysis of the contemporary relevance of transition theory. Nursing Inquiry 10, 66-77. Eriksson, C., Salander, P., Hamberg, K., 2007. Men's experiences of intense fear related to childbirth investigated in a Swedish qualitative study. The Journal of Men’s Health & Gender 4, 409-418. Erlandsson, K., Lindgren, H., 2009. From belonging to belonging through a blessed moment of love for a child - the birth of a child from the fathers' perspective. Journal of Men’s Health 6, 338-344. Fenwick, J., Bayes, S., Johansson, M., 2012. A qualitative investigation into the pregnancy experiences and childbirth expectations of Australian fathers-to-be. Sexual and Reproductive Healthcare 3, 3-9. Flemming, K., 2007. Synthesis of qualitative research and evidence-based nursing. British Journal of Nursing 16, 616-620. Genesoni, L., Tallandini, M. A., 2009. Men's psychological transition to fatherhood: an analysis of the literature, 1989-2008. Birth 36, 305-318. Goodman, J. H., 2005. Becoming an involved father of an infant. Journal of Obstetric, Gynecologic, and Neonatal Nursing 34, 190-200. Greenhalgh, R., Slade, P., Spiby, H., 2000. Fathers' coping style, antenatal preparation, and experiences of labor and the postpartum. Birth 27, 177-184. Grobman, W., Kavanaugh, K., Moro, T., De Regnier, R.-A., Savage, T., 2010. Providing advice to parents for women at actutely high risk of periviable delivery. Obstetrics and Gynecology 115, 904-909. Gungor, I., 2007. Effects of fathers' attendance to labor and delivery on the experience of childbirth in Turkey. Western Journal of Nursing Research 29, 213-231. Hallgren, A., Kihlgren, M., Forslin, L., Norberg, A., 1999. Swedish fathers' involvement in and experiences of childbirth preparation and childbirth. Midwifery 15, 6-15. Hildingsson, I., Cederlof, L., Widen, S., 2011. Fathers' birth experience in relation to midwifery care. Women and Birth 24, 129-136. Johansson, M., Hildingsson, I., 2013. Intrapartum care could be improved according to Swedish fathers: mode of birth matters for satisfaction. Women and Birth 26, 195-201. Johansson, M., Hildingsson, I., Fenwick, J., 2013. Important factors working to mediate Swedish fathers' experiences of a caesarean section. Midwifery 29, 1041-1049. Johansson, M., Rubertsson, C., Radestad, I., Hildingsson, I., 2012. Childbirth - an emotionally demanding experience for fathers. Sexual & Reproductive Healthcare 3, 11-20. Johnson, M. P., 2002. An exploration of men's experience and role at childbirth. The Journal of Men's Studies 10, 165-182.
Kainz, G., Eliasson, M., von Post, I., 2010. The child's father, an important person for the mother's well-being during the childbirth: a hermeneutic study. Health Care for Women International 31, 621-635. Kululanga, L. I., Malata, A., Chirwa, E., Sundby, J., 2012. Malawian fathers' views and experiences of attending the birth of their children: a qualitative study. BMC Pregnancy and Childbirth 12, 141. Lindberg, I., Engström, T., 2013. A qualitative study of new fathers’ experiences of care in relation to complicated childbirth. Sexual & Reproductive Healthcare 4, 147-152. Longworth, H. L., Kingdon, C. K., 2011. Fathers in the birth room: what are they expecting and experiencing? A phenomenological study. Midwifery 27, 588-594. Major, C.H., Savin-Baden, M., 2010. An introduction to quality research synthesis: Managing the information explosion in social science research. New York: Routhledge Press. Premberg, A., Carlsson, G., Hellstrom, A. L., Berg, M., 2011. First-time fathers' experiences of childbirth--a phenomenological study. Midwifery 27, 848-853. Premberg, A., Lundberg, I., 2006. Fathers' experiences of childbirth education. Journal of Perinatal Education 15, 21-28. Rosich-Medina, A., Shetty, A., 2007. A paternal experiences of pregnancy and labour. British Journal of Midwifery 15, 66-74. Sandelowski, M., Docherty, S., Emden, C., 1997. Focus on qualitative methods. Qualitative metasynthesis: issues and techniques. Research in Nursing & Health 20, 365-371. Sapkota, S., Kobayashi, T., Takase, M., 2012. Husbands' experiences of supporting their wives during childbirth in Nepal. Midwifery 28, 45-51. Sengane, M.L., 2009. The experience of black fathers concerning support for their wives/partners during labour. Curationis 32, 67-73. Simbar, M., Nahidi, F., Tehrani, F. R., Ramezankhani, A., 2010. Fathers' educational needs for perinatal care in urban Iran: a qualitative approach. Journal of Biosocial Science 42, 633-641. Steen, M., Downe, S., Bamford, N., Edozien, L., 2012. Not-patient and not-visitor: a metasynthesis fathers' encounters with pregnancy, birth and maternity care. Midwifery 28, 362-371. Symon, A., Lee, J., 2003. Including men in antenatal education: Evaluating innovative practice. Evidence- Based Midwifery 1, 9-12. Walsh, D., Downe, S., 2005. Meta-synthesis method for qualitative research: a literature review. Journal of Advanced Nursing 50, 204-211. Walsh, D., Downe, S., 2006. Appraising the quality of qualitative research. Midwifery 22, 108-119. Vehvilainen-Julkunen, K., Liukkonen, A., 1998. Fathers' experiences of childbirth. Midwifery 14, 10-17.
Table 1. Mapping of methods, concepts and findings of the included studies. Metho ds percep tions and concep ts
Bäckstr öm et al. (2011)
Erlandsso n & Lindgren (2009)
Johanss Johnso on et al. n (2012) (2002)
Kululang a et al. (2012)
Longwort h et al.(2011)
Premberg et al. (2011)
Sapkota et al. (2012)
Sampl e
10 first‐ time fathers
16 fathers (7 first‐ time and 9 repeat fathers)
21 fathers (9 first‐ time and 12 repeat fathers)
20 fathers
20 fathers (9 first‐ time and 11 repeat fathers)
11 first‐ time fathers
10 first‐ time fathers
12 first‐ time fathers
Mode of birth
Spontan eous vaginal births
Elective CS n=7
Elective Sponta CS n=18 neous vaginal Emerge births ncy CS n=3
Spontane ous vaginal births n=16
Emergen cy and elective CS, forceps and spontane ous vaginal births represent ed
Vaginal births with a healthy baby
Spontan eous vaginal births
Vaginal n=5 Emergen cy CS n=4
CS n=4
Setting One Two Swedish district hospital maternity clinics in Sweden
The area of one Swedish County
Two GP One city areas in of Englan Malawi d
One Two maternity Swedish unit in hospitals England
One birth centre in Nepal
Qualit ative metho d
Themati c analysis (Burnar d et al. 2008)
Discour se analysis (Burma n & Parker, 1993)
Heidegge rian hermene utical phenome nology
Themati c analysis (Boyatzi s, 1998)
Content analysis (Graneh eim & Lundma n 2004)
Phenome nology (Giorgi, 1985; 1997; 2000)
Qualitati ve content analysis (Granehe im & Lundman , 2004)
Phenomen ological life‐world approach (Dahlberg 2006; Dahlberg et al. 2008)
Data collecti on
Intervie ws 1 week after birth
Interview s 8 days and 6 weeks after birth
Intervie ws 7‐16 months after birth
Intervie ws 1 week after birth
Interview s within two years after birth
Interview s (antenata l and) 1 week after birth
Notion of validit y
Transfer ability discusse d
Transfera Validity bility and discussed transfer ability discusse d
Not discuss ed
Limitatio ns discusse d
Limitatio Transferab ns ility discussed discussed
Limitatio ns discusse d
Positio Not ning of discusse resear d cher
Research Not ers pre‐ discusse understa d nding discussed
Not discuss ed
Not discusse d
Pre‐ understa nding and process discussed
Researcher s’ approach discussed
Translati on and interpre tation bias discusse d
From belonging through a blessed moment of love for a child
None present ed
Motivati on; Positive experien ces; Negative experien ces; Reflectio n and resolutio ns
None presente d
An interwove n process pendulatin g between euphoria and agony
None presente d
Reactio Shame n to the and birth embarras
Disconne ction with
A process into the unknown
Being positive towards
Main theme s, concep ts or essenti al meani ng
Being involved or being left out
Anticipa ting a CS On the day: the CS birth Mediati ng factors for men’s experie nces
Interviews Intervie 4‐6 weeks ws 1 after birth week after birth
Sub‐ theme s or
An Changing allowing perspecti atmosp ve of life
The health‐ care
sub‐ catego ries
here Balance d involve ment Being seen Feeling left out
Being in a team relations played a hip key role, Living controll through a ed birth life environ change ment, feeling prepare d: men’s previou s CS experie nces and knowing date and time of birth
sment
A mutually attenda nce shared Helpless experience ness and Hesitati unprepar On the on To guard ed periphery and Poor of events support emotion during Men’s Health the al care reason woman labour reaction provider for In an s – male Control being exposed present partner Being Fatherho position tension, at able to od with childbir and support exclusion beginning hidden th at birth strong from Need to emotions be decision‐ and reconnec making mentally tion process prepare Men’s perceiv ed role during childbir th
pregnanc y and labour
d Enlighte nment
Table 2. Essential criteria for appraising quality of the included studies. Bäckström et Erlandsson & Johansson et Johnson Kululanga et al. (2011) Lindberg (2009) al. (2012) (2002) al. (2012) Clear scope for purpose? yes yes yes yes yes Contextualised by existing literature? yes yes yes yes yes Method apparent? yes yes yes yes yes Data collection apparant and appropriate? yes yes yes yes yes Sampling strategy appropriate? yes yes yes yes yes Analytic approach appropriate? yes yes yes yes yes Context involved and dwelling in analysis? no yes yes no yes Audit trail given? yes yes yes no yes Data supporting interpretation? yes yes yes yes yes Researcher reflexivity? no yes yes no yes Senistivity to ethical yes yes yes yes yes
concerns? Relevance and transferability?
yes
yes
yes
yes
yes
Quality assessment tool described by Walsh & Downe (2006).
Longworth et Premberg et al. (2011) al. (2011) yes yes yes yes yes yes yes yers yes yes no yes no yes no yes yes yes no no yes yes yes yes
Sapkota et al. (2012) yes yes yes yes yes no yes no yes yes yes yes
Table 3. The analyzing process of interpreting data, and the shift from overarching first order themes into second and third order themes. First order themes Second order themes Third order themes Wanted to be present Being there Desiring respectful participation Preparing for the unique challenge of Being involved or not Issue of involvement birth The impact of being prepared Being prepared Midwives make a difference Being supportive was emotionally Relationship with partner Being sensitive to my partner challenging Experiencing overwhelming Feelings experienced feelings The birth: agony to ecstasy A life change that is unknown A crucial change in my life The staff played an important role Being influenced by staff
Table 4. Developed second order themes across studies.
Being there
Issue of involvem ent
Being prepared
Being sensitive to my partner
Experienci ng overwhelm ing feelings
Bäckströ m et al. (2011)
Admissibl e atmosphe re and essential to be balanced involved
Essential to be balanced involved
Important to be prepared in order to feel supported
Relation through communicat ion and wanting to give support
Overwhelm No ing contradicti ng feelings
Through attitudes and behavior which had impact on their sense of being supporte d and ability to support the partner
Erlandss on & Lindgren (2009)
Not discussed; belonging to each other seems to be implicit and natural.
Through No belonging to each other. To participat e not discussed but implied in descriptio n
Supporting the partner
Overwhelm Existenti ing feelings al thoughts , fragility of life and a deeper belongin g to each other
Receiving explanati on made them calm
Through staff talking, explaining and giving instructio ns which
Through staff talking, explaining and giving instructio ns which
They couldn’t help the partner and felt because of that useless
Overwhelm No ing in relation to the fact of surgery and un‐ empathic
Through attitudes and behavior which had impact on
A crucial Being change influence in my d by staff life
Johanss on et al. (2012)
Through previous experience s, knowledge and receiving a
Johnson (2002)
made them feeling safe, involved and supported but having a difficult position
made them feeling safe, involved and supported
time point. This important for being in control, experience d it good and with no worries, could be focused
In order to be a good father but sometime s forced to be present
Through being useful part of the birth and cutting the umbilical cord was regarded as a ritual passage
Lack of preparedn ess
behavior of the staff
the birth experienc e and ability to cope
Transitio n to fatherho od
What learned antenatal led to be a better supporter , and through attitudes which had impact over their ability to cope
Inability to support partner and to share labour pain
Emotional contradicti ng feelings; struggle with labour pain, culture and about meeting the baby
Kululang a et al. (2012)
Wanted to support the partner but they had a difficult position
They Lack of didn’t feel preparedn involved ess in any decisions leading to inability to help
They couldn’t give support, leading to frustration, being useless and
Overwhelm The risk ing feelings of death of uselessness and frustration due to exclusion,
Through attitudes and behavior; they felt unprepar ed, ignored
Longwor th et al.(2011 )
Prember g et al. (2011)
of being there and didn’t feel involved in any decisions
the partner and feelings of uselessne ss and frustratio n evoked
Different levels of involveme nt, wishing to be involved and not in the same time leading to focus on practical issues, being in the periphery of the event
Wishing to be involved and not in the same time, focused on practical issues, different levels of involveme nt
Seems to be natural and a mutual shared event
Described as an interwove n process in order to support the partner
scare
unfamiliarit y, partner’s pain, bleeding, need for surgery and the birth of the baby
Prepared through education but not always sufficient
About communicat ion with partner and as a part of a team
The birth of the baby was the best moment
Becomin g a father, a new family created, from being de‐ to re‐ connect ed
Through behavior which had impact on their ability to cope and be involved
The importanc e of being prepared
A team with the partner, supporting her and the one who knows her best, thou a submissive role
Alter between happiness and despair, suffer in relation to partner’s labour pain
Existenti al thoughts , fragility of life and a process into the unknow n; being a father a change in life; more meaning ful when
Seen as expertise but not always acted in an empathic way which had impact on their ability to cope
but also recognize d as a father
baby was born Sapkota et al. (2012)
Positive towards attendanc e and being involved but also a hesitation , cultural discourag ed, a lack of privacy; took turn with a female relative
Willingnes s to be involved thou a lack of privacy; took turn with a female relative
A need to be mentally prepared
Wanted to support but not able to share labour pain except watching
Being No frustrated when the loved one suffered, hided own feelings and fear in order not to worry the partner
Wanted the staff making them comforta ble in the labour room
• • • •
Men wanted to be actively involved in labour and birth, respected for what they could contribute. The birth was a unique and challenging event requiring preparation. Overwhelming feelings and inadequacy in their ability to support their partner were expressed. Midwives made a difference for the birth experience of the life changing event of birth.
A meta-synthesis of fathers' experiences of their partner's labour and the birth of their baby M. Johansson RN RM PhD, J. Fenwick RM PhD, Å. Premberg RN RM PhD
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S0266-6138(14)00127-2 http://dx.doi.org/10.1016/j.midw.2014.05.005 YMIDW1541
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Midwifery
Received date: 19 February 2014 Revised date: 29 April 2014 Accepted date: 4 May 2014 Cite this article as: M. Johansson RN RM PhD, J. Fenwick RM PhD, Å. Premberg RN RM PhD, A meta-synthesis of fathers' experiences of their partner's labour and the birth of their baby, Midwifery, http://dx.doi.org/10.1016/j.midw.2014.05.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
A META-SYNTHESIS OF FATHERS’ EXPERIENCES OF THEIR PARTNER’S LABOUR AND THE BIRTH OF THEIR BABY
Authors: Johansson M RN RM PhD Senior lecturer₁, Fenwick J RM PhD Professor₂, Premberg Å RN RM PhD Research Leader₃
₁ Corresponding Author: Karolinska Institutet Södersjukhuset, Department of Clinical Science and Education, Sjukhusbacken 10, SE-118 83 Stockholm, Stockholm, Sweden. Fax number: +46 8 616 20 89; Telephone number: +46 70 241 52 75; E-mail: [email protected]
₂ School of Nursing and Midwifery, Centre for Health Practice Innovation (HPI), Griffith Health Institute, Griffith University, University Drive, Meadowbrook , Queensland 4131. Clinical Chair Gold Coast University Hospital, Parklands Queensland, Australia. Telephone number: +61410479985; E-mail: [email protected]
₃ Primary Health Care, Research and Development Unit, Närhälsan, Kungsgatan 12, Gothenburg, Sweden. Telephone number: +46706653157; E-mail: [email protected]
ABSTRACT Objective: To develop greater understanding of how expectant fathers experience their partner’s labour and the subsequent birth of their baby. Design: A qualitative meta-synthesis. Data were search for in CINAHL, PubMed, Psych Info and SCOPUS. Setting: Eight studies conducted in England, Malawi, Nepal and Sweden were included. Participants: One hundred and twenty fathers with experiences of their partner having a spontaneous vaginal, assisted or surgical birth. Measurements and Findings: 1st order themes were identified and subsequently grouped into seven 2nd order themes. Finally through a process of exploring patterns and connections seven 3rd order themes were developed which produced new insights into the men’s experiences of labour and birth. This meta-synthesis revealed that most men wanted to be actively involved in their partner’s labour, present at the birth and respected for what they could contribute. Men recognised that birth was a unique event that may be potentially challenging requiring a level of preparation. There were also men who felt pressured to attend. During the actual experience of labour men commonly expressed overwhelming feelings and inadequacy in their ability to support their partner. They particularly struggled with the ‘pain’ of labour. Midwives were subsequently identified as best placed to make a significant difference to how men perceived their experiences of labour and what they described as the life changing event of birth. Key conclusions: The expectant fathers’ birth experiences were multidimensional. Many were committed to being involved during labour and birth but often felt vulnerable. Being prepared and receiving support were essential elements of positive experience as well as contributing to their ability to adequately support the labouring woman. Implications for practice: Men’s ability to actively prepare for, and be supported through, the labour and birth process influences their perceptions of the childbirth event as well as their sense of connection to their partner. Couples should be given opportunities to explore expectations and how these may influence their own construction of their role during the birth process. While the role of expectant fathers in labour and birth should be facilitated and supported arguably their wish not to participate should be afforded the same respect. Keywords: childbirth; experience; fathers; meta-synthesis
INTRODUCTION In most western nations expectant fathers are encouraged to be involved and actively participate in their partner’s labour and the subsequent birth of their infant. Men, however, often report the experience of labour and birth as demanding and one that evokes a range of contradictory emotions (Johansson et al., 2012). For example some time ago Hallgren et al. (1999) described how men could go from feeling overwhelmed and helpless to expressing the experience of witnessing the birth as “the best in life” (p.12). Anxiety in pregnancy is a common emotion (Capogna et al., 2007; Rosich-Medina and Shetty, 2007) as is vulnerability both of which are linked to men’s feelings of uncertainty surrounding the labour and birth process and the role they are expected to play (Sengane, 2009; Draper, 2003). Negative emotions are also commonly fuelled by expectant fathers’ fears for the safety of their partner and the unborn baby (Vehviläinen-Julkunen and Liukkonen, 1998; Eriksson et al., 2007). Despite this there is evidence that men can regard the experience as positive (Johansson et al., 2012) especially when they perceived they are well supported by the midwives providing care to their female partner (Johansson et al., 2012; Lindberg and Engström, 2013).
The growing body of qualitative work and the development of methodological techniques to synthesis the findings of individual qualitative studies has facilitated the research communities ability to create new and integrative interpretations that are greater than the sum of each included study (Flemming, 2007). As a result qualitative meta-synthesis has become increasingly popular. For example in a recent meta-synthesis of 23 qualitative studies by Steen et al. (2012) explored the experiences of men in relation to pregnancy, birth and the first six months of fatherhood. A number of major themes were identified that produced insights into issues such as risk, uncertainty, exclusion, support and the reality of fatherhood. Similarly Chin et al. (2011) explored fathers' experiences of their transition to fatherhood. Eight articles were examined and three themes extracted that described men’s emotional reactions to their role as a new father, how they redefined their sense of self as well as their relationship with partner. These findings add to the earlier work of Goodman (2005) who used the same approach to synthesis the findings from ten articles with the intention of describing men’s experiences of fatherhood from birth to 20 months. In this work new insights were gained into men’s expectations and intentions, how they learned to confront the reality of their role as an involved father and how it could be an emotional rewarding experience. More recently Dheensa et al. (2013) published a meta-synthesis that examined men's experiences of
antenatal screening. From the 18 qualitative studies men’s emotional conflict early in pregnancy, their focus on gaining information and how they subsequently influenced decision-making on screening were explored.
Conducting a qualitative meta-synthesis is one way to make sense of the available literature and is becoming increasingly popular. Although used somewhat extensively in the area of men’s childbirth experience the majority of work has focused on the entire childbirth episode including transition to fatherhood. There has been limited work on using the technique of meta-synthesis to examine only one aspect of men’s experiences such as the labour and birth process. Using a more targeted approach is likely to assist in establishing a greater understanding of how men integrate this unique experience and thus provide maternity health care professionals with additional strategies to ensure women and their partners have a positive experience of childbirth. The aim of this study was therefore to develop greater understanding of how expectant fathers experience their partner’s labour and the subsequent birth of their baby.
METHODS Study design The techniques described by Major and Savin-Baden (2010) guided the process of our quality research synthesis which included four distinct levels: (i) systematic approach to the identification of articles, (ii) analysis of the themes common to all selected studies resulting in the identification of what are commonly referred to as 1st order themes, (iii) synthesis of data across studies producing 2nd order themes and finally (iv) interpretation which generated the 3rd order themes or findings of the meta-synthesis. During this process concepts, metaphors and quotes were used to form patterns in the synthesized interpretation.
Identification of articles With the intension to get a wide sample of articles covering the subject of interest we chose databases from different disciplines; CINAHL, PubMed, Psych Info and SCOPUS. The keywords used were “father “OR “dad “OR “male” OR “man” AND “childbirth” OR “parturition” AND “experience” AND “qualitative”. The terms were varied according to the
index system of each database. Other parameters included were articles written in English and published in 2000 or later in peer-reviewed journals. The database searches were repeated with the last occasion being June the 19th 2013. A template for inclusion and exclusion criteria was created in order to guide our review. An article was included if it described a qualitative study that aimed to explore fathers’ experience of their partner’s labour and birth (including spontaneous vaginal birth, assisted delivery and caesarean section). Studies with disparate geography or cultural backgrounds were included if they met the inclusion criteria. The rationale for this decision was to ensure a global view of fathers’ birth experiences was represented. Articles were excluded when couples were the participants, pregnancy and fatherhood were the focus of the study and if a quantitative or mixed method design had been used. The judgment for inclusion was based on the title and subsequently the abstract. If it was unclear then the entire article was read and assessed against the inclusion and exclusion criteria. In the database CINAHL we received 22 hits and of these two articles were included in our qualitative meta-synthesis (Erlandsson and Lindgren, 2009; Johnson, 2002). In PubMed 33 hits were retrieved and three included (Johansson et al., 2013; Kululanga et al., 2012; Premberg et al., 2011). Eighteen articles were found in Psych Info but none fulfilled the inclusion criteria. Finally 129 hits were received in SCOPUS and of these six were included (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Kululanga et al., 2012; Longworth and Kingdon, 2011; Premberg et al., 2011; Sapkota et al. 2012). Two of the authors (MJ, ÅP) independently assessed the papers for inclusion, and the final number (n=8) was then agreed by consensus of all three authors. Table 1 presents the mapping of methods, concepts and findings of the included studies. The included articles were also assessed for quality using the criteria developed by Walsh and Downe (2006); see Table 2 for further details. Analysis In the next stage we scrutinized the included articles looking for common features. Firstly all the themes from each study were listed. In this way we commenced the process of identifying apparent relationships across the studies. Questions such as ‘Which findings were clear?’ and ‘Which themes were explored?’ guided the process. Subsequently concepts within themes were extracted and compared across studies. Seven themes were identified that were common
across all the studies. These were labeled as 1st order themes and described as ‘Wanted to be present’, ‘Being involved or not’, ‘The impact of being prepared’, ‘Relationship with partner’, ‘Feelings experienced’, ‘A life change that is unknown’, and finally, ‘The staff played an important role’ (Table 3). Synthesis data across studies In the next phase of the meta-synthesis process ‘data’ used to highlight the themes were extracted. Similarities and differences were identified through a process of constant comparison. In this way seven 2nd order themes emerged that created new perspectives of the fathers’ experiences of labour and birth (Major and Savin-Baden, 2010 p.63). These themes were labeled: ‘Being there’, ‘Issue of involvement’, ‘Being prepared’, ‘Being sensitive to my partner’, ‘Experiencing overwhelming feelings’, ‘A crucial change in my life’ and ‘Being influenced by staff’ (Table 4). Interpretation of data The final step in the process involved reviewing patterns and connections between the 1st and 2nd order themes. At this level, metaphors, concepts and contexts were also compared. This involved carefully re-reading the included studies and examining each one for relationships between the developed themes. Data was discussed between the authors, synthesized and eventually the authors agreed on the construction of five 3rd order themes (shown in Table 3 and described below). Ethics Seven studies included a statement about ethics approval. While the article by Johnson (2002) did not the research design was considered to be ethically sound. In all papers study participants were anonymous and direct quotes could not be attributed to an identified individual.
FINDINGS The eight qualitative studies included in the meta-synthesis involved 120 fathers from four countries (England, Malawi, Nepal and Sweden). While the majority of men’s experiences were those related to their partner having a spontaneous vaginal birth men experiences of the
labour process leading to other birth modes were also represented within the themes as there was little differentiation in the data set (Table 1). Five 3rd order themes were developed using the process outlined above. In a meta-synthesis these become the final findings of the study (Major and Savin-Baden, 2010). These 3rd order themes were labeled; ‘Desiring respectful participation’, ‘Preparing for the unique challenge of birth’, ‘Midwives make a difference’, ‘Being supportive was emotionally challenging’ and ‘The birth: agony to ecstasy’ (Table 3).
Desiring respectful participation The vast majority of expectant fathers described a strong desire to participate in their partner’s labour and be present at the birth of their child (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Kululanga et al., 2012; Premberg et al., 2011). Men were keen to provide physical and emotional support to their partner. For many the decision to ‘be there’ was not something they consciously thought about but was rather an expectation (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Johansson et al., 2013). Likewise others described the decision to attend their partners labour and birth as ‘natural’ (Premberg et al., 2011) and/or expressed the importance of being part of the team (Johnson, 2002; Longworth and Kingdon, 2011). Men articulated how important it was that their status as the father of the baby be acknowledged and that their presence be ‘valued’ (Kululanga et al., 2012; Sapkota et al., 2012). Men wanted to be considered as a ‘part of the labouring couple’ (Backstrom and Hertfelt Wahn, 2011 p.70) and as integral to the process of birth (Premberg et al., 2011). In addition men believed that ‘being present’ was about being ‘a good father’ which reflected their commitment to their partner and family unit (Johnson, 2002 p.176). For these men feeling actively engaged, involved and providing support to their partner was important and an essential element of a positive experience (Johnson, 2002; Kululanga et al., 2012). Physical support regularly included holding their partners hand (Erlandsson and Lindgren, 2009; Premberg et al., 2011; Sapkota et al., 2012) , talking to her, and standing by her side (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Johansson et al., 2013; Johnson, 2002; Kululanga et al., 2012; Longworth and Kingdon, 2011; Premberg et al., 2011; Sapkota et al., 2012). If and when their female partner was distressed men talked about trying to calm them through body contact and by talking (Erlandsson and Lindgren, 2009). Providing comfort (Johnson, 2002), being their partner’s advocate and ‘spokesman’ and interpreting her needs (Kululanga et al., 2012; Premberg et al.,
2011) were common emotional support activities. Supporting the woman also meant ‘protecting’ her. This involved ‘filtering’ information and ‘pleading’ for her wishes to prevent and/or reduce the risk of her getting upset (Premberg et al., 2011). Providing support created a feeling of involvement and security in the men (Backstrom and Hertfelt Wahn, 2011). In addition participating and being present at the birth was viewed as a unique and exclusive opportunity to ‘bond’ with their new-born (Johnson, 2002; Kululanga et al., 2012).
Not surprisingly some men described feeling hesitant whilst also curious about being present and involved (Kululanga et al., 2012; Sapkota et al., 2012). Others articulated, however, that the decision to participate in their partners labour and birth was based on the expectation of others such as partners (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Johnson, 2002; Kululanga et al., 2012; Sapkota et al., 2012), peers (Kululanga et al., 2012) and health care professionals (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Johnson, 2002). Still other men in this meta-synthesis had not expected to be present at all (Longworth and Kingdon, 2011) while the work of Sapkota et al. (2012) highlighted men’s experiences in a cultural context where it was not common for men to be ‘birth companions’ to their partners. What was evident during the synthesis process was that when men had been hesitant but encouraged to be present at the birth they more commonly reported feelings of helplessness and frustration (Kululanga et al., 2012; Sapkota et al., 2012) while others talked about being “in the way” (Johnson, 2002 p.174).
Preparation for the unique challenge of birth Childbirth was considered ‘unknown territory’ for most first-time fathers (Johansson et al., 2013; Premberg et al., 2011; Sapkota et al., 2012) ‘To tell you the truth, I didn’t know about childbirth’ (Sapkota et al., 2012 p.47). As such men’s mental and physical preparation was seen as not only vital but crucial to their ability to be actively involved in the labour and birth process (Backstrom and Hertfelt Wahn, 2011; Johansson et al., 2013; Longworth and Kingdon, 2011; Premberg et al., 2011; Sapkota et al., 2012). As one first-time father said: ‘Husbands should be mentally prepared … the birthing process could be discussed… we could be informed about how to help our wives’ (Sapkota et al., 2012 p.48). Preparation consisted of reading (Backstrom and Hertfelt Wahn, 2011), talking to friends (Backstrom and Hertfelt Wahn, 2011; Johnson, 2002), and attending antenatal classes (Backstrom and Hertfelt Wahn, 2011; Johnson, 2002; Longworth and Kingdon, 2011). For some preparing with the woman was especially important (Backstrom and Hertfelt Wahn, 2011; Johansson et al.,
2013; Premberg et al., 2011; Sapkota et al., 2012). Fathers, who attended antenatal classes, were deemed to be better positioned to be actively involved during birth (Longworth and Kingdon, 2011). Likewise those men attending classes were better prepared to support the woman and to cope with labour and any critical events during the process (Johnson, 2002). Men with previous birth experiences usually drew on these which ultimately enhanced feeling of preparedness generating feeling of positivity and a sense of control. ‘We knew what to expect, and we had a good experience from the first surgery, we could relay pretty much on our previous experience’ (Johansson et al., 2013 p.6).
A lack of preparation for the labour and birth process was more likely to create feeling akin to being ‘out of control’ (Johnson, 2002; Longworth and Kingdon, 2011) which subsequently hampered men’s ability to undertake a ‘supportive’ role (Johnson, 2002). In this state unfamiliar birth environments were experienced as ‘scary’; ‘if I was better prepared for what was going to happen, I would have been more use to her (partner)…’ (Johnson, 2002 p.177). Furthermore, when lacking confidence fathers experienced an inability to support the woman physically (Sapkota et al., 2012). In the case of a caesarean section, the fathers were not always prepared for being present in the theatre which was a challenging experience. In these circumstances receiving continuous information from the health care professionals involved was crucial; ‘They talked the whole time and explained and said what they were doing ... that was very good’ (Johansson et al., 2013 p.5).
Midwives make a difference The level of engagement and active involvement that men experienced during the labour and birth process depended greatly on the quality of communication and interactions they shared with health care professionals. Positive respectful behaviour and language by professionals impacted greatly on men’s sense involvement (Johansson et al., 2013; Premberg et al., 2011). Being continually kept informed generated feelings of safety and inclusion (Backstrom and Hertfelt Wahn, 2011; Johansson et al., 2013) and consequently made a significant difference to the men’s sense of control (Johansson et al., 2013; Longworth and Kingdon, 2011).
When men perceived they were working in partnership with the midwife they felt more able to support their partners which subsequently enhanced their feelings of being ‘useful’ (Premberg et al., 2011). As one first-time father said: ‘The support I got was that they answered my questions ... and when they gave good answers it calmed me, and when I was
calm my girlfriend was too…’ (Backstrom and Hertfelt Wahn, 2011 p.69). The men appreciated midwives providing instructions on how to provide additional physical support (Backstrom and Hertfelt Wahn, 2011; Premberg et al., 2011) such as massage (Backstrom and Hertfelt Wahn, 2011; Premberg et al., 2011; Sapkota et al., 2012) and breathing techniques (Backstrom and Hertfelt Wahn, 2011; Johnson, 2002; Sapkota et al., 2012), how to assist their partner effectively use the nitrous oxide (Backstrom and Hertfelt Wahn, 2011) and how to ensure their partners stayed well hydrated and energised (Sapkota et al., 2012). Another firsttime father said: ‘I felt good when the midwife showed me, because then I was able to be involved’ (Backstrom and Hertfelt Wahn, 2011 p.70). Likewise health care professional needed to demonstrate through their actions that men had ‘permission’ to not only be present in the birth space but to ‘own’ it (Backstrom and Hertfelt Wahn, 2011; Erlandsson and Lindgren, 2009; Premberg et al., 2011). An important consequence of positive interactions was that when men felt ‘safe’ they could relax and were more able to accept and trust the process of birth (Backstrom and Hertfelt Wahn, 2011).
However there was evidence that health care professionals were not always attentive to men’s needs or provided them with a high level of support. If men were unable to receive the information they needed they became less involved and felt insecure. In situations like these men often tried to find out what was going on by reading the faces and gesture of the professionals (Johansson et al., 2013; Premberg et al., 2011). A father, who experienced his partner’s emergency caesarean section, said: ‘They didn’t tell me what happened… It would have been better had they done this… That would have made me feel more secure’ (Johansson et al., 2013 p.5). While positive interactions were applauded negative ones could be incredibly detrimental. In one study an expectant father recounted how a midwife had told him the reason men were present at birth was to ‘teach them a lesson’ (Johnson, 2002 p.174). Premberg et al. (2011) demonstrated how men could be forced to undertake an activity they didn’t want or had not agreed to when a new father being passed the scissors to cut his newborn’s umbilical cord even though he had previously stated this is something he did not want to do. Hospital routines and feeling unwelcome in the space also acted as obstacles to men being able to engage in a positive way. When men were left out or ignored their sense of disconnection lead not only to frustration and distress (Johnson, 2002) but often forced men to take a passive role in terms of supporting their partner (Johnson, 2002; Longworth and Kingdon, 2011).
Being supportive was emotionally challenging Regardless of the preparation undertaken, their level of involvement and the support of staff, being a strong calm companion in the process of childbirth could be challenging and emotionally overwhelming experience for men (Erlandsson and Lindgren, 2009; Sapkota et al., 2012). A woman’s ability to manage her labour and work with her contractions commonly influenced her male partner’s experience; if she could cope with labour pain he remained ‘calm’ (Premberg et al., 2011). Alternatively as the pain of labour increased, men reported becoming less able to deal with the situation (Johansson et al., 2013; Johnson, 2002; Kululanga et al., 2012; Premberg et al., 2011). In addition, any perceived ‘conflict’ around pain relief caused men stress (Johnson, 2002). Watching their partner was described as ‘hard’ and often gave rise to overwhelming feelings of despair (Erlandsson and Lindgren, 2009; Premberg et al., 2011), frustration (Erlandsson and Lindgren, 2009; Kululanga et al., 2012; Premberg et al., 2011; Sapkota et al., 2012), helplessness (Erlandsson and Lindgren, 2009; Johansson et al., 2013; Johnson, 2002; Premberg et al., 2011) and powerlessness (Johnson, 2002). Men really struggled with knowing what to do (Johnson, 2002; Kululanga et al., 2012; Sapkota et al., 2012) or how to help ease their partner’s pain. Commonly these feelings lead men to feel like they had failed their partner in some way (Kululanga et al., 2012). Likewise men often struggled to support their partners (Backstrom and Hertfelt Wahn, 2011; Johnson, 2002) in adverse circumstances such as bleeding or when an assisted birth was required (Johansson et al., 2013; Sapkota et al., 2012). In these situations men described ‘fighting’ to remain calm, ‘hiding’ their emotions and ‘chocking back tears’ in order to sustain and support their partner (Erlandsson and Lindgren, 2009; Premberg et al., 2011; Sapkota et al., 2012); ‘I was telling her not to worry, but I myself was worried deep inside’ (Sapkota et al., 2012 p. 48). Being physically present, whilst at the same time feeling somewhat ‘sidelined’ or a ‘by-stander’ in the events going on around them, was a difficult position for the men to assume (Johansson et al., 2013; Longworth and Kingdon, 2011). Again the dominant emotions elicited were stress, panic, fear and helplessness. ‘I wanted to help, but I felt left out, I could not do anything ... I wanted to help somehow, but could not‘ (Backstrom and Hertfelt Wahn, 2011 p.71). Although having another female relative or support person present often reduced men’s anxiety but this was not always the case.
The birth: agony to ecstasy During the labour process men’s emotions fluctuated. To some extent regardless of how well labour was progressing most men worried that something might go ‘wrong’. For some these fears resulted in men constructing childbirth as ‘life-threatening’ (Erlandsson and Lindgren, 2009; Johnson, 2002; Premberg et al., 2011) where they envisaged either the woman, her baby or both could die (Erlandsson and Lindgren, 2009; Johansson et al., 2013; Kululanga et al., 2012; Premberg et al., 2011). Men found it hard to compare the moment of their child’s birth with any other experience; words such as ‘happiness’ (Erlandsson and Lindgren, 2009; Johansson et al., 2013; Premberg et al., 2011) and ‘proud’ (Erlandsson and Lindgren, 2009) were common as was ‘relief’ (Erlandsson and Lindgren, 2009; Johansson et al., 2013; Premberg et al., 2011). ’I was overwhelmed with joy to see our new baby. It was amazing that at the same time all the pain my partner was experiencing ceased’ (Kululanga et al., 2012 p.5). The strength and overwhelming nature of the emotions fathers ‘felt’ at ‘seeing’ their baby born were somewhat unexpected and commonly described as taking them by ‘surprise’ (Erlandsson and Lindgren, 2009; Johnson, 2002; Kululanga et al., 2012). In Johnson’s (Johnson, 2002) work the act of cutting the umbilical cord was steeped in emotion as it symbolised men’s ‘rite of passage’ to separate one into two (Johnson, 2002). For men the moment of birth represented the time that they actually became a father which they ultimately considered to be life changing event (Erlandsson and Lindgren, 2009; Johansson et al., 2013; Johnson, 2002; Kululanga et al., 2012; Longworth and Kingdon, 2011; Premberg et al., 2011); ‘It was pure joy, I didn’t know whether to laugh or to cry (Longworth and Kingdon, 2011 p.591).
DISCUSSION As previous research has highlighted, the majority of men included in this meta-synthesis expressed a desire to participate in and support their female partner during the labour and birth process (Abushaikha and Massah, 2012; Dellman, 2004; Eriksson et al., 2007; Gungor, 2007; Simbar et al., 2010). Men wanted to be actively involved and of some practical help to their partner. This may be a reflection of the reality that half of the studies included in the analysis were of Swedish origin where fathers’ involvement is commonly constructed as a social ‘norm’. Asserting the right to participate also appeared to be a reflection of men’s need to be acknowledged as an important partner in the childbirth process and an avenue through
which they could establish a ‘connection’ with their new-born infant (Eriksson et al., 2007; Simbar et al., 2010; Vehvilainen-Julkunen and Liukkonen, 1998). Arguably this could be the result of work that has consistently demonstrated men feel left out or side-lined during a woman’s pregnancy (Fenwick et al., 2012). Not with-standing there were men who felt participation was an expectation of their partner and/or midwife rather than a free choice (Bartlett, 2004; Dellman, 2004; Eriksson et al., 2007).
Regardless of expectations around participation our analysis revealed that for male partners labour and birth was a unique life event which held a number of potential challenges. Preparing, not only for the event itself, but to actively support their female partner was considered important by most. Indeed the work of Kainz et al., (2010) argues that men’s ability to communicate the woman’s wishes and engender feeling of security plays a significant role in the facilitating a positive experience for them both. However, in line with the findings of others (Bartlett, 2004; Genesoni and Tallandini, 2009; Hallgren et al., 1999) many men described feeling mentally ill prepared for such an emotionally charged event. The unpredictable nature of labour and birth, and their partner’s reaction to the pain of labour were particularly influential. As a result, and similar to the previous findings of a literature review undertaken by Genesoni and Tallandini (2009), men often struggled to support their partners, felt uncomfortable, distressed and vulnerable in the birth space, and expressed the need for additional support for themselves. Certainly positive support from midwives and/or other maternity health care professionals made a significant difference to the men’s experiences. As others have found (Danerek and Dykes, 2008; Grobman et al., 2010; Hildingsson et al., 2011; Johansson et al., 2012) the level of involvement that men experienced during the labour and birth process depended greatly on the quality of communication and interactions they shared with health care professionals. Expectant fathers appreciated receiving information in an honest manner (Danerek and Dykes, 2008), and being provided with clear information so they could more fully understand the situation and be better able to participate in decision making (Grobman et al., 2010). When men perceived they were working in partnership with the midwife they felt more able to support their partners which subsequently enhanced their feelings of being ‘useful’. In a meta-synthesis of fathers’ experiences of pregnancy, birth and maternity care Steen et al. (2012) identified that good support from clinicians helped men to manage and balance the emotional work associate with their partners labour and birth.
On the contrary a lack of support left men feeling worried, helpless and unsafe irrespective of cultural background. Being given little or no information or inconsistent advice has been described as distressing by expectant fathers (Johansson et al., 2012). In other work where expectant fathers perceived their partners received poor care and midwives were considered obstructive men expressed high levels of dissatisfaction (Johansson and Hildingsson, 2013).
Men’s own gendered preconceptions might also impact on their ability to positively participate during childbirth. Anthropologists Angelova and Temkina (2010) have described two models of role participation for fathers in childbirth. The first, labelled the family orientated role, talks about full participation, partnership and appropriate training, which has many similarities with the descriptions of some of the men in our analysis. The second model, described as situational and formal, is a reflection of the more masculine hegemony role of men which includes the tasks of observing and controlling. It may be that when men become distressed they are more likely to relapse into a masculine hegemonic way of behaving which automatically places them in a ‘spectator’ role (for example watching a piece of machinery as opposed to lending psychical support to partner during contractions). Taking a ‘distant’ or disengaged position (Johnson, 2002; Longworth and Kingdon, 2011) may enhance feelings of distress and an inability to manage or cope with the situation at hand. Dolan and Coe (2011) interpretations are useful here as they advocate that for men to be truly present during labour and birth they need to shed the traditional masculine values of power and control. Not surprisingly in cultures where participation in childbirth is a rather new occurrence men’s experience of feeling distant and distressed, as described in Kululanga (2012) and Sapkota et al. (2012), is likely to have its origins in the traditional construction of gender roles. In addition a lack of privacy in the labour room and unfriendly staff were other issues that made participation difficult for expectant fathers in developing countries.
Facilitating opportunities for new, as well as, fathers with previous birth experiences to engage with each other may be one strategy that would better help men gain more realistic expectations around the labour and birth process and feel better prepared (Premberg and Lundberg, 2006; Symon and Lee, 2003). Having said this there is evidence that some men do not seek out opportunities to prepare for birth. Certainly authors such as Case et al. (2005) and earlier Baker and Pettigrew (1999) have highlighted how, when faced with a perceived
stressful situation, avoiding information becomes a common coping strategy as ‘paying attention’ actually causes mental discomfort (Case et al., 2005). Behavior of this nature has been termed ‘blunting’ (Greenhalgh et al., 2000 p.179). Work by Greenhalg et al. (2000) showed that male ‘blunters’ attending antenatal classes were less likely to have a fulfilling childbirth experience compared to those with similar coping styles who did not attend classes. Arguably it may be that men engage in this type of avoidance behavior because they are fearful. For example Swedish researcher Eriksson et al. (2007), when exploring fathers’ experiences of childbirth fear, described how expectant fathers routinely kept themselves occupied with other activities and made excuses for not engaging in an effort to withdraw themselves from situations where the forthcoming childbirth might be discussed.
Methodological considerations Conducting a qualitative research synthesis is a way of making sense of the available literature and developing new understanding that can inform practice. An initial core issue in conducting a qualitative meta-synthesis is deciding which studies are about the same phenomenon (Sandelowski et al., 1997). In this study we focused therefore exclusively on fathers’ birth experiences of labour and birth as opposed to others who have included pregnancy and/or early fatherhood (Chin et al., 2011; Goodman, 2005; Steen et al., 2012). We found, however, that few of the qualitative studies had used similar methodological approaches. Arguably one could question whether it is appropriate and subsequently possible to synthesize such data given the different and sometimes contradicting ways that data sets are handled. Nevertheless, the qualitative paradigm considers truth as subjective and multiple, and knowledge as constructed. As such Walsh and Downe (2005) argue the legitimacy of including a variety of approaches in a meta-synthesis. In line with this argument we made the decision to include a range of study methodologies and to include not only the final description of the analysis but all the direct published quotes. Quotes from the primary sources were used to generate a ‘rich description’ and maintain sensitivity to the original language. In addition we included descriptive tables of the included studies as well as analysis tables describing how the themes were emerged (Walsh and Downe, 2005). Taking this approach we believed strengthened the trustworthiness and credibility of the study findings ensuring they were open and transparent (Major and Savin-Baden, 2010).
Notwithstanding the synthesis relied on published results and not original data. Furthermore, no unpublished i.e. ‘grey literature’ or studies not written in English were included. This may lead to publication bias. However large sample size may impede deep analysis. As Bondas and Hall (2007) recommend no more than ten articles should be included in a meta-synthesis.
Conclusion and clinical implications The fathers’ birth experiences were complex and multidimensional. While many men felt committed to the concept of being involved and supportive during their partners labour and birth they subsequently found themselves feeling vulnerable, confused and distressed. Being prepared and receiving sufficient information and situational support were key components of a positive birth experience. The actual moment of ‘birth’ was considered by most to be a life changing event. Positive respectful behaviour and language by professionals impacted greatly on men’s sense of involvement. Being continually kept informed generated feelings of safety and inclusion and consequently made a significant difference to the men’s sense of self. Couples should be given opportunities to explore expectations and how these may have influenced their own construction of their role. While men’s role to participate should be respected arguably their wish not to participate should be afforded the same respect.
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Table 1. Mapping of methods, concepts and findings of the included studies. Metho ds percep tions and concep ts
Bäckstr öm et al. (2011)
Erlandsso n & Lindgren (2009)
Johanss Johnso on et al. n (2012) (2002)
Kululang a et al. (2012)
Longwort h et al.(2011)
Premberg et al. (2011)
Sapkota et al. (2012)
Sampl e
10 first‐ time fathers
16 fathers (7 first‐ time and 9 repeat fathers)
21 fathers (9 first‐ time and 12 repeat fathers)
20 fathers
20 fathers (9 first‐ time and 11 repeat fathers)
11 first‐ time fathers
10 first‐ time fathers
12 first‐ time fathers
Mode of birth
Spontan eous vaginal births
Elective CS n=7
Elective Sponta CS n=18 neous vaginal Emerge births ncy CS n=3
Spontane ous vaginal births n=16
Emergen cy and elective CS, forceps and spontane ous vaginal births represent ed
Vaginal births with a healthy baby
Spontan eous vaginal births
Vaginal n=5 Emergen cy CS n=4
CS n=4
Setting One Two Swedish district hospital maternity clinics in Sweden
The area of one Swedish County
Two GP One city areas in of Englan Malawi d
One Two maternity Swedish unit in hospitals England
One birth centre in Nepal
Qualit ative metho d
Themati c analysis (Burnar d et al. 2008)
Discour se analysis (Burma n & Parker, 1993)
Heidegge rian hermene utical phenome nology
Themati c analysis (Boyatzi s, 1998)
Content analysis (Graneh eim & Lundma n 2004)
Phenome nology (Giorgi, 1985; 1997; 2000)
Qualitati ve content analysis (Granehe im & Lundman , 2004)
Phenomen ological life‐world approach (Dahlberg 2006; Dahlberg et al. 2008)
Data collecti on
Intervie ws 1 week after birth
Interview s 8 days and 6 weeks after birth
Intervie ws 7‐16 months after birth
Intervie ws 1 week after birth
Interview s within two years after birth
Interview s (antenata l and) 1 week after birth
Notion of validit y
Transfer ability discusse d
Transfera Validity bility and discussed transfer ability discusse d
Not discuss ed
Limitatio ns discusse d
Limitatio Transferab ns ility discussed discussed
Limitatio ns discusse d
Positio Not ning of discusse resear d cher
Research Not ers pre‐ discusse understa d nding discussed
Not discuss ed
Not discusse d
Pre‐ understa nding and process discussed
Researcher s’ approach discussed
Translati on and interpre tation bias discusse d
From belonging through a blessed moment of love for a child
None present ed
Motivati on; Positive experien ces; Negative experien ces; Reflectio n and resolutio ns
None presente d
An interwove n process pendulatin g between euphoria and agony
None presente d
Reactio Shame n to the and birth embarras
Disconne ction with
A process into the unknown
Being positive towards
Main theme s, concep ts or essenti al meani ng
Being involved or being left out
Anticipa ting a CS On the day: the CS birth Mediati ng factors for men’s experie nces
Interviews Intervie 4‐6 weeks ws 1 after birth week after birth
Sub‐ theme s or
An Changing allowing perspecti atmosp ve of life
The health‐ care
sub‐ catego ries
here Balance d involve ment Being seen Feeling left out
Being in a team relations played a hip key role, Living controll through a ed birth life environ change ment, feeling prepare d: men’s previou s CS experie nces and knowing date and time of birth
sment
A mutually attenda nce shared Helpless experience ness and Hesitati unprepar On the on To guard ed periphery and Poor of events support emotion during Men’s Health the al care reason woman labour reaction provider for In an s – male Control being exposed present partner Being Fatherho position tension, at able to od with childbir and support exclusion beginning hidden th at birth strong from Need to emotions be decision‐ and reconnec making mentally tion process prepare Men’s perceiv ed role during childbir th
pregnanc y and labour
d Enlighte nment
Table 2. Essential criteria for appraising quality of the included studies. Bäckström et Erlandsson & Johansson et Johnson Kululanga et al. (2011) Lindberg (2009) al. (2012) (2002) al. (2012) Clear scope for purpose? yes yes yes yes yes Contextualised by existing literature? yes yes yes yes yes Method apparent? yes yes yes yes yes Data collection apparant and appropriate? yes yes yes yes yes Sampling strategy appropriate? yes yes yes yes yes Analytic approach appropriate? yes yes yes yes yes Context involved and dwelling in analysis? no yes yes no yes Audit trail given? yes yes yes no yes Data supporting interpretation? yes yes yes yes yes Researcher reflexivity? no yes yes no yes Senistivity to ethical yes yes yes yes yes
concerns? Relevance and transferability?
yes
yes
yes
yes
yes
Quality assessment tool described by Walsh & Downe (2006).
Longworth et Premberg et al. (2011) al. (2011) yes yes yes yes yes yes yes yers yes yes no yes no yes no yes yes yes no no yes yes yes yes
Sapkota et al. (2012) yes yes yes yes yes no yes no yes yes yes yes
Table 3. The analyzing process of interpreting data, and the shift from overarching first order themes into second and third order themes. First order themes Second order themes Third order themes Wanted to be present Being there Desiring respectful participation Preparing for the unique challenge of Being involved or not Issue of involvement birth The impact of being prepared Being prepared Midwives make a difference Being supportive was emotionally Relationship with partner Being sensitive to my partner challenging Experiencing overwhelming Feelings experienced feelings The birth: agony to ecstasy A life change that is unknown A crucial change in my life The staff played an important role Being influenced by staff
Table 4. Developed second order themes across studies.
Being there
Issue of involvem ent
Being prepared
Being sensitive to my partner
Experienci ng overwhelm ing feelings
Bäckströ m et al. (2011)
Admissibl e atmosphe re and essential to be balanced involved
Essential to be balanced involved
Important to be prepared in order to feel supported
Relation through communicat ion and wanting to give support
Overwhelm No ing contradicti ng feelings
Through attitudes and behavior which had impact on their sense of being supporte d and ability to support the partner
Erlandss on & Lindgren (2009)
Not discussed; belonging to each other seems to be implicit and natural.
Through No belonging to each other. To participat e not discussed but implied in descriptio n
Supporting the partner
Overwhelm Existenti ing feelings al thoughts , fragility of life and a deeper belongin g to each other
Receiving explanati on made them calm
Through staff talking, explaining and giving instructio ns which
Through staff talking, explaining and giving instructio ns which
They couldn’t help the partner and felt because of that useless
Overwhelm No ing in relation to the fact of surgery and un‐ empathic
Through attitudes and behavior which had impact on
A crucial Being change influence in my d by staff life
Johanss on et al. (2012)
Through previous experience s, knowledge and receiving a
Johnson (2002)
made them feeling safe, involved and supported but having a difficult position
made them feeling safe, involved and supported
time point. This important for being in control, experience d it good and with no worries, could be focused
In order to be a good father but sometime s forced to be present
Through being useful part of the birth and cutting the umbilical cord was regarded as a ritual passage
Lack of preparedn ess
behavior of the staff
the birth experienc e and ability to cope
Transitio n to fatherho od
What learned antenatal led to be a better supporter , and through attitudes which had impact over their ability to cope
Inability to support partner and to share labour pain
Emotional contradicti ng feelings; struggle with labour pain, culture and about meeting the baby
Kululang a et al. (2012)
Wanted to support the partner but they had a difficult position
They Lack of didn’t feel preparedn involved ess in any decisions leading to inability to help
They couldn’t give support, leading to frustration, being useless and
Overwhelm The risk ing feelings of death of uselessness and frustration due to exclusion,
Through attitudes and behavior; they felt unprepar ed, ignored
Longwor th et al.(2011 )
Prember g et al. (2011)
of being there and didn’t feel involved in any decisions
the partner and feelings of uselessne ss and frustratio n evoked
Different levels of involveme nt, wishing to be involved and not in the same time leading to focus on practical issues, being in the periphery of the event
Wishing to be involved and not in the same time, focused on practical issues, different levels of involveme nt
Seems to be natural and a mutual shared event
Described as an interwove n process in order to support the partner
scare
unfamiliarit y, partner’s pain, bleeding, need for surgery and the birth of the baby
Prepared through education but not always sufficient
About communicat ion with partner and as a part of a team
The birth of the baby was the best moment
Becomin g a father, a new family created, from being de‐ to re‐ connect ed
Through behavior which had impact on their ability to cope and be involved
The importanc e of being prepared
A team with the partner, supporting her and the one who knows her best, thou a submissive role
Alter between happiness and despair, suffer in relation to partner’s labour pain
Existenti al thoughts , fragility of life and a process into the unknow n; being a father a change in life; more meaning ful when
Seen as expertise but not always acted in an empathic way which had impact on their ability to cope
but also recognize d as a father
baby was born Sapkota et al. (2012)
Positive towards attendanc e and being involved but also a hesitation , cultural discourag ed, a lack of privacy; took turn with a female relative
Willingnes s to be involved thou a lack of privacy; took turn with a female relative
A need to be mentally prepared
Wanted to support but not able to share labour pain except watching
Being No frustrated when the loved one suffered, hided own feelings and fear in order not to worry the partner
Wanted the staff making them comforta ble in the labour room
• • • •
Men wanted to be actively involved in labour and birth, respected for what they could contribute. The birth was a unique and challenging event requiring preparation. Overwhelming feelings and inadequacy in their ability to support their partner were expressed. Midwives made a difference for the birth experience of the life changing event of birth.